Amman, Jordan - As Waleed exhales, a puff of fresh smoke mingles with the odour of stale smoke that pervades his small shop in a poor area of Amman. He draws again deeply on his cigarette. "I wish a pack of cigarettes were 10 dinars [about $14]," he says. "That's the best way to quit smoking."
Nevertheless, cigarettes in Jordan actually became cheaper in early 2013 when tobacco companies cut prices by about 25 percent, putting the government and Jordanian society at a crossroads in the battle against smoking.
"Why not decrease the prices of vegetables and meat?" asks 42-year-old Waleed, who started smoking at the age of 12 and has tried numerous times to quit. "That's what we need." He holds up a pack of cigarettes and shakes it angrily. "This is poison. The government can solve this problem."
Doctors, anti-tobacco activists and many others have reacted with similar outrage to the price cut, blaming tobacco companies for the initial decision and the government for failing to hike cigarette taxes. A pack of Marlboro Golds that once cost 1.8 Jordanian dinars ($2.54) is now just 1.4 JD ($1.98), while the price of a pack of Winstons dropped to 1.2 JD ($1.69) from 1.6 JD ($2.26).
We expect countries to compensate for any decrease in actual cost [of cigarettes] by increasing by the equivalent in tax.
Both tobacco companies and the government cite the need to fight cigarette smuggling, which costs the government tax revenue, as justification for lower prices. But studies on smuggling challenge this claim, showing that lower prices are not the most effective way to fight smuggling, and that the industry itself is often complicit.
Lower prices will bring an "inevitable increase in the number of children and young individuals taking up smoking" and "have a catastrophic effect on combating smoking related diseases", Liam Robertson, a communications officer for the World Health Organisation (WHO) in Jordan, said.
Being a country of six million that already spends a staggering 500m JD ($706m) per year on smoking-related diseases, Jordan cannot afford higher smoking rates. It also has obligations as a signatory to WHO's Framework Convention on Tobacco Control to fight smoking.
"We expect countries to compensate for any decrease in actual cost [of cigarettes] by increasing by the equivalent in tax," said Dr Akram Eltom, WHO's representative in Jordan.
A smoking society
"Everyone here smokes - even women, even children," says 36-year-old Mahmoud Husain. A smoker himself, he is one of Amman's rare taxi drivers abiding by Public Health Law 47, which forbids smoking in public places, including public transport, restaurants, and government buildings. The law is poorly enforced and generally flouted. Even government officials, including MPs and one former prime minister, smoke in parliament and ministry offices.
According to a 2009 Global Health study, nearly half of Jordan's male adult population smokes, although many Jordanians believe the rate is closer to 70 percent. Five percent of women also smoke, as do 16 percent of children aged 13-15.
Smoking nargileh, or hookah, is also rising, as it is more socially acceptable. Few people realise, though, that smoke inhaled in one nargileh session can be comparable to that of 100 cigarettes.
"This is a disaster," said Dr Feras Hawari, who heads the Cancer Control Office at Jordan's King Hussein Cancer Centre. "A tsunami of non-communicable diseases is going to hit the country in about 10 to 15 years." He pointed outside his office window to a large construction zone, where the cancer centre is being expanded from about 165 beds to about 370.
In 2009, Jordan had 4,798 new cases of cancer, according to the country's latest cancer registry, a number Hawari expects to double within a decade. Smoking is a major risk factor for cancer and cardiovascular and respiratory diseases, which together accounted for 54 percent of deaths in Jordan in 2008. But despite the obvious costs, the government has a long way to go in its battle against smoking.
The government's role
After tobacco companies lowered prices, the ministry of health immediately sent a letter to the prime minister explaining the consequences of the decision, said Dr Malek Habashneh, head of the Tobacco Awareness Department at the Ministry of Health.
He explained, however, that the government could neither approve nor disapprove of the price drop due to "a gap in legislation". Nevertheless, "the ministry of finance has the right to increase taxes on cigarettes at any time", he said in an interview.
"Economic studies around the world have shown that tobacco taxes are the most cost-effective policy in reducing tobacco use," said Anne-Marie Perucic, an economist who studies taxation and tobacco control and works with the WHO's department on tobacco control.
Riad al-Shreideh, Jordan's director general of taxation, however, declared that cigarette prices are not the government's responsibility. "Our responsibility, as the income and sales tax department, is only to say that the cigarette companies have to pay a certain tax," he said.
Shreideh did not know whether the government would raise taxes. "When you raise taxes, smuggling will increase," he said. Tobacco companies "say that when we raise taxes, they lose profit", he added, and companies threatened to pull out of Jordan if the government raises taxes on cigarettes, which it last did in 2010.
"That kind of threat is to be expected," said Eltom. "If companies threaten to pull out from the country, how many jobs will be lost, compared to if they stay in the country, how many lives will be lost?"
A growing movement
Habashneh is working hard to raise awareness and convince decision-makers of the importance of controlling tobacco usage. "But we have limited resources," he said.
Currently, the kingdom has 184 liaison officers authorised to ticket violators of the public health law - unless violations occur on public transportation, where police can intercede. According to Habashneh, 226 violations were sent to court in 2011 and 581 warnings issued.
"I need 500 officers to control this issue," Habashneh said, adding that he hoped to increase the number of officers to 400 within two years. The government also runs three smoking cessation clinics in the country. The capacity of each is 10 to 12 people per day, and they are open two days a week, according to Habashneh.
This really has to be a national effort. We are going to fight this. It might take us a while, but we're not going to quit.
"These are very desperately needed service outlets," Eltom said, "but we expect more than three." Simultaneously critical of Jordan's efforts and optimistic about its prospects in fighting smoking, Eltom said that by allowing cigarette prices to drop, the government is "eroding [its] own successes". Yet he is certain that Jordan can devise simple and creative tactics to reduce smoking.
One way would be "for people to vote with their feet and their wallets", he suggested. Another would be for local governments to offer tax incentives to non-smoking restaurants. "There's the capability within Jordan to be doing that," he said, praising Jordanians as "very positively oriented towards behaviour change that is healthy".
Dr Larissa Aluar, co-founder of Women Against Indoor Smoking, now called Tobacco Free Jordan, has seen a cultural shift in recent years. Non-smokers' rights actually exist now, and smoke-free homes and restaurants are on the rise. Jordan also has several other anti-smoking groups, such as the Jordanian Anti-Smoking Society.
"It's not something that one person can do," Aluar said of the fight against tobacco. She called on the government to lead, adding, "they are role models, at the end of the day".
Despite the challenges that lie ahead - increasing taxes, raising awareness, enforcing laws - those within Jordan's nascent anti-smoking movement remain undeterred. "This really has to be a national effort," said Hawari. "We are going to fight this. It might take us a while, but we're not going to quit."
Hawari believes the price cut in Jordan "is a very well-calculated move by the tobacco industry".
"Despite its professed opposition to criminal activity, the tobacco industry benefits from smuggling in several ways," said a 2003 WHO report. Illicit trade lowers tobacco prices, increasing overall sales, it described, and much of this trade "has occurred with the knowledge of the major cigarette companies themselves, and would not occur without their compliance", the report added.
Philip Morris International wrote in an email: "We were forced to decrease the prices of our cigarettes in Jordan to address the serious problem of illicit smuggled cigarettes," which it said in 2012 accounted for 46 percent of all cigarettes sold in the country, costing the government about $190m in lost taxes.
British American Tobacco (BAT) declined to respond to questions regarding the decrease in prices.
But Perucic, the WHO economist, says "smuggling estimates provided by the tobacco industry are often exaggerated".
"They want to keep this fear within governments, because it's not in their interest that taxes are increased." Nor is lowering tobacco prices an ideal means of combating illicit trade, she added. Effective ways of fighting smuggling include governmental actions such as strengthening customs capacity, increasing penalties and improving information exchanges with neighbouring countries.
In other countries, Perucic explained, what the tobacco industry has done is decrease the price of a certain product. "And then at some point they would raise it again. They don't stay with the low price for a long time. It's usually a short-term strategy to increase their market share."
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